allcare cco Referral/Prior Authorization Grid Contents 2-3 Alcohol and Drug 4-6 Mental Health 4 Adult Outpatient 4 Adult 5 Child Outpatient 5-6 Child 6 Peer Delivered Services 7 Physical Health 7-8 Provider Services 9 Diagnostic Services 9-12 Surgical Procedures & Services (ASC and Hospital) 13 Vision Services 13 Non-emergent Transportation 14-15 Hospital Services 15 Pharmacy Services 15 Hospice Services 15 Skilled Nursing Facility Services 16 Home Health Services 16 Hearing Services 16 Dietary Counseling/Medical Education Services 16 Chemical Dependency Services 17 Dental Services 17-18 Equipment and Supplies
AllCare CCO Alcohol and Drug Referral/Prior Authorization Grid Effective 01/01/2017 For alcohol and drug services contact the contracted provider: Curry County: Curry Community Health (541) 247-4082 Jackson County: Addictions Recovery Center (541) 779-1282; OnTrack, Inc. (541) 772-1777 Josephine County: OnTrack, Inc. (541) 955-9227 Modifiers are to be used on all codes: UA Adolescent Residential A&D HB Adult Residential A&D HF Substance Abuse/Outpatient Modifier Codes/Comments Prior Auth Required Outpatient - Adult and Adolescent Services provided in the community by a contracted Member may self-refer No Alcohol and Drug Provider Buprenorphine / Suboxone J0571-J0575, J0592 Probuphine (implant) J3490 Naltrexone J2315 Detoxification ASAM level IV-D Medically managed HF H0008-H0009 Yes detoxification ASAM level III.7-D Medically monitored HF H0010-H0011 Yes detoxification ASAM level III.2-D Clinically managed HF H0012-H0013 Yes detoxification ASAM level III-D Ambulatory detoxification HF H0014 Yes monitoring Residential - Adult ASAM level III.1 Clinically-Managed HB H0018-H0019 Yes Low Intensity treatment ASAM level III.3 Clinically-Managed HB H0018-H0019 Yes Medium Intensity treatment ASAM level III.5 Clinically-Managed HB H0018-H0019 Yes High Intensity treatment ASAM level III.7 Medically-Monitored HB H0018-H0019 Yes Intensive Inpatient Services Residential - Adolescent ASAM level III.1 Clinically-Managed UA H0018-H0019 Yes Low Intensity treatment ASAM level III.3 Clinically-Managed Medium Intensity treatment UA H0018-H0019 Yes 2 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
AllCare CCO Alcohol and Drug Referral/Prior Authorization Grid Effective 01/01/2017 For alcohol and drug services contact the contracted provider: Modifiers are to be used on all codes: Curry County: Curry Community Health (541) 247-4082 UA Adolescent Residential A&D Jackson County: Addictions Recovery Center (541) 779-1282; OnTrack, Inc. (541) 772-1777 HB Adult Residential A&D Josephine County: OnTrack, Inc. (541) 955-9227 HF Substance Abuse/Outpatient ASAM level III.5 Clinically-Managed High Intensity treatment ASAM level III.7 Medically-Monitored Intensive Inpatient Services Modifier Codes/Comments Prior Auth Required UA H0018-H0019 Yes UA H0018-H0019 Yes 3 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
AllCare CCO Mental Health Referral/Prior Authorization Grid Effective 01/01/2017 For mental health services contact the community mental health program in your county: Curry Community Health: (541) 247-4082 or toll-free 1 (877) 739-4245 Jackson County Mental Health: (541) 774-8201 or toll-free 1 (888) 363-8755 Options for Southern Oregon (Josephine County and Douglas County): (541) 476-2373 Adult Outpatient Services provided in the community and coordinated by Community Health Program. Adult Acute Inpatient Hospital Psychiatric Care (admission to a hospital behavioral health unit or on psychiatric hold in a hospital hold unit) Sub-Acute Psychiatric Care (admission to a non-hospital hold unit, crisis resolution center, crisis respite) Residential Treatment (Adult Foster Care, Residential Treatment Home, Residential Treatment Facility, Secured Residential Treatment Facility) Codes/Comments Member may self-refer, contact Community Mental Health Program H2013 Paid by Fee-For-Service OHP Prior Auth Required No Electroconvulsive Therapy (ECT) 90870 Health Program and AllCare Medical Director. Transcranial Magnetic Stimulation 90867-90869 Applied Behavior Analysis (age 19 and older) Long-Term Psychiatric Care (State Hospitalization and Post Acute Intermediate Psychiatric Care) Services must be rendered by a Certified Provider in Oregon. Paid by Fee-For-Service OHP. Referrals are only coordinated from Acute Inpatient Hospital Psychiatric Care prior to admit into Oregon State Hospital. Referrals are coordinated by the Community Mental Health Agency, the Hospital, and the CCO. Determination and payments are done by the State Addictions and Mental Health Division. Yes. AMH makes determination. Supported Employment H2023 Assertive Community Treatment (ACT) H0039 4 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
AllCare CCO Mental Health Referral/Prior Authorization Grid Effective 01/01/2017 For mental health services contact the community mental health program in your county: Curry Community Health: (541) 247-4082 or toll-free 1 (877) 739-4245 Jackson County Mental Health: (541) 774-8201 or toll-free 1 (888) 363-8755 Options for Southern Oregon (Josephine County and Douglas County): (541) 476-2373 Child Outpatient Services provided in the community and coordinated by Community Health Program. Child Wraparound Acute Codes/Comments Member may self-refer, contact Community Mental Health Program 90882, H0038, H2014, T1023, G1076, G1077 This is a specialized service that is currently offered to children with Child Welfare involvement. If you have questions regarding referral or eligibility, contact the Community Mental Prior Auth Required No Sub-Acute H2013 Respite H0045, S5151, T1005, H0002 Intensive Community-based Treatment Service (ICTS) Behavioral Rehabilitative Services (BRS) Psychiatric Residential Treatment Services (PRTS) (plus interactive code add-on 90785), 90862, H0004, T0123, 90882, G0176, G0177 90887, 90791 (plus interactive add-on code 90785), H0036, H0038, S9484, H2011, 90847, H2010, 90792, H2021, H2022, 90832 (plus interactive code add-on 90785), 90833, 90834, 90836, 90837 Placement at BRS Facility paid by Department of Human Services (DHS) or Oregon Youth Authority (OYA), outpatient MH services paid 90849, 96101, H2032, H0034, T1016, H0031, H2014, T1013, 90846, H0032, 90853 (plus interactive code add-on 90785), 90862, H0004, T0123, 90882, G0176, G0177, 90887, 90791 plus interactive add-on code 90785, H0036 H0019 5 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
AllCare CCO Mental Health Referral/Prior Authorization Grid Effective 01/01/2017 For mental health services contact the community mental health program in your county: Curry Community Health: (541) 247-4082 or toll-free 1 (877) 739-4245 Jackson County Mental Health: (541) 774-8201 or toll-free 1 (888) 363-8755 Options for Southern Oregon (Josephine County and Douglas County): (541) 476-2373 Codes/Comments Prior Auth Required Day Treatment H0037, H2012 Secured Children s Inpatient Program (SAIP) Secured Adolescent Inpatient Program (SAIP) Applied Behavior Analysis (age 0 through age 18) Peer Delivered Services Peer Support Specialist, Peer Wellness Specialist (Youth, Adult, and Family Member) Referrals are only coordinated from Acute Inpatient Hospital Psychiatric Care prior to admit into Oregon State Hospital. Referrals are coordinated by the Community Mental Health Agency, the Hospital, and the CCO. Determination and payments are done by the State Addictions and Mental Health Division. H0018-H0019 H0018-H0019 H0038 Yes. AMH makes determination. Yes. AMH makes determination. No. 6 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
Provider Services (in office setting- place of service 11) Referrals to Specialist (with exception of routine OB care and contraceptive management) (for vision see Vision Services) Pediatric Assessment 96110-96111 Neuropyschology testing 96118 Preventive and Wellness Services Screening Colonoscopy (under age 50) Bone mass measurement (if over the benefit limit - once every 2 years) Prostate cancer screening (under age 50) Anesthesia Services Pain management 62310-62311, 62318-62319, 62350-62370, 64400-64425, 64445-64530, 64620-64640, 95990-95991 Spinal Cord Stimulator 63650-63688, 95970-95982 Injections and Treatments Acupuncture 97810-97814 Allergy Injections 95115-95180 Botox Injections J0585-J0588 7 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
Bursa Injections 20600-20611 No (must be covered diagnosis)(not covered for spine diagnosis that fall on Lines 351 or 407) Carpal Tunnel Surgery 64721 Chiropractic 98940-98943 Coaptite 51715, L8606 Circumcision (less than 28 days of age) 54150, 54160 no Dental procedure under general anesthesia 00170 *dental procedure must be covered Neurostimulators 64553-64595 Osteopathic Manipulation 98925-98929 Photodynamic/Photochemotherapy/Laser treatment/actinotherapy 96567-96571, 96900, 96910-96913, 96920-96922 Sinus Endoscopy 31295-31297 Tympanostomy 69433 Varicose vein treatment 36468-36471, 36475-36479 (see Vision Services for eye procedures) Ziconotide J2278 8 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
Diagnostic Services (Do not require an auth for services necessary and reasonable to diagnose the presenting condition and/or preventative services, except as listed) Genetic testing (beyond amniocentesis and routine 81161-81504, 81519, 88245-88264, 88271-88299 pre-natal screening) MRI 70336, 70540-70543, 70551-70553, 71550-71552, 72141-72158, 72195-72197, 73218-73223, 73718-73723, 74181-74183, 75557-75565, 77058-77059, 77084 Myelography 62302-62305, 72240-72270 Pet Scan 78608-78609, 78811-78816 Sleep Studies 95782-95783, 95800-95811 Video EEG (Inpatient) 95812-95830, 95950-95962 Capsule Endoscopy 91110 Surgical Procedures & Services (ASC and Hospital - place of service 22 or 24) (Services should be provided in the allowed place of service setting as identified by CMS and/or DMAP) General anesthesia and facility charges related *must be a covered dental service to dental services* Elective surgery General surgery excluding services below (see Vision Services for eye procedures) 9 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
General Surgery Angiogram 36013-36254 no Port A Cath placement and removal 36555-36571, 36575-36590 no Biopsy 10021-10022, 11100-11101, 11755,19081-19086,19100-19101, 20200-20251, no 23065-23066, 24065-24066, 25065-25066, 27040-27041, 27323-27324, 27613-27614, 30100, 32096-32098, 32400-32405, 32607-32609, 37200, 38500-38530, 40490, 40808, 41100-41108, 42100, 42400-42405, 42800-42806, 43605, 45100, 47000-47001, 47100, 48100-48102, 49180, 50200-50205, 53200, 54100-54105, 54500-54505, 54800, 55700-55706, 56605-56606, 57100-57105, 58100-58110, 60100, 62267, 62269, 64795, 65410, 67346, 67810, 68100, 68510, 68525, 69100-69105 Placement of breast localization device 19281-19288 no ERCP 43260-43278 no G Tube placement, change & removal 49440-49446, 49450-49465 no Incision and Drainage 10030, 10060-10061, 10080-10081,10120-10121, 10140, 10160, 10180, 19000- no 19001, 19020, 20005,21501-21502, 21510, 22010, 22015, 23030-23044, 23930-24006, 25028-25040, 26990-26992, 27030, 27301-27303, 27603-27604, 27610, 28001-28005, 30000, 30020, 41000-41009, 41015-41018, 42000, 42700, 42720, 42725, 44900, 45000-45005, 45020, 46040, 46045, 46050, 46060, 49020, 49040, 49060-49062, 49405-49407, 52700, 53040, 53060, 53080-53085, 54015, 54700, 56405, 56420, 57022-57023, 60000, 67700, 68020, 68400, 68420, 69000-69020 Lumbar Puncture 62270-62272 no 10 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
Paracentesis/Thoracentesis 32554-32557, 49082-49083 no Vascular embolization or occlusion 37241-37244, 36481 no Vasectomy 55200-55250, 55400-55450 (Must have DMAP form appropriately completed by member within DMAP time limits) Cardiac Surgery Heart Catheterization 93451-93462, 93530-93568 no Pacemaker/Generator change/defibrillator 33202-33249, 33262-33264,33270-33273 no Operative ablation 33250-33266, 33261, 93609, 93613, 93619-93624, 93640-93644, 93650- no 93657 Implantation / Removal Cardiac event recorder 33282, 33284 no no Cardioversion 92960-92961 no Cardiac Stent Placement/CABG 33510-33523, 33530, 33533-33536, 92920-92944, 35600 no Urology Ureteral Stent 50382-50387 no (internal removal with/without replacement) TURP/Laser Coagulation 52601-52649 no Lithotripsy 50080-50081, 50590 no Cystoscopy 52000-52318, 52320-52356, 52400-52442 no 11 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
ENT PE tube removal 69420 no GYN Cerclage of cervix 59320-59325, 59871 no D & C 59812-59830, 59870 no Ectopic pregnancy 59100-59151 no Cesarean Section (scheduled or emergent) 59510-59515, 59618-59622 (see Hospital Services for admission no requirements) Vaginal delivery 59400-59414, 59610-59614 (see Hospital Services for admission no requirements) Curettage / Episiotomy 59160, 59200, 59300 no Hysterorrhaphy 59350 no Hysteroscopy (diagnostic or biopsy) 58555, 58558 no Removal of adnexa 58661 no Tubal Ligation 58565, 58600-58615, 58670-58671 (Must have DMAP form appropriately no completed by member within DMAP time limits) Dermatology Destruction malignant skin lesion 11600-11646, 17260-17286 no 12 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
Vision Services Routine visual exam (beyond OHP benefit limitation) Medical - consult/office visit (annual diabetic exam does not require referral) Eyeglasses/Fittings/Polycarb lenses (beyond OHP benefit limitation) *Must use Sweep Optical Vision Procedures Blepharoplasty 15823 Strabismus surgery 67311-67345 Ptosis repair 67900-67912 Reconstruction 67930-67935, 67950-67975 Eye procedures (applies to in-office, ambulatory surgery center and outpatient hospital) Non-emergent Transportation 13151-13153, 65091-65093, 65101-65105, 65125-65175, 65205-65265, 65270-65290, 65400-65600, 65710-65757, 65760-65770, 65772-65775, 65778-65782, 65800-66030, 66150-66250, 66500-66505, 66600-66635, 66680-66770, 66820-66825, 66830-66984, 66982-66990, 67005-67043, 67101-67115, 67120-67121,67141-67145, 67208-67218, 67220-67229, 67250-67255, 67400-67450, 67500-67515, 67550-67570, 67710-67715, 67820-67850, 67875-67882, 67914-67924, 67938, 68040-68200, 68330-68340, 68360-68371, 68440-68505, 68520, 68530-68850 Routine non-emergent transportation Benefit is administered through ReadyRide: (541) 479-7920 Refer to ReadyRide policy no 13 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
Air transport A0430-A0431 (all claims for air transport, emergent and non-emergent are subject for review) Ambulance transport A0426, A0428 Hospital Services Emergent Department Emergent department visit no Scheduled visits in the emergent department unless service otherwise specified in PA grid Inpatient admission Emergent hospital admission Requires notification within 48 hours no Inpatient hospital admission (scheduled) also requires notification within 48 hours of admission Inpatient Rehabilitative Care also requires notification within 48 hours of admission Specialty hospital (such as Long Term Acute also requires notification within 48 hours of admission Care) Outpatient Hospital Services Outpatient Surgical Services - (No separate authorization required for facility if surgical procedure is prior authorized when applicable) Scheduled visits in an outpatient facility unless service otherwise specified in PA grid Infusion services 14 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
Outpatient Therapy/Rehabilitation Services Biofeedback/Neurofeedback 90901-90911 Cardiac or Pulmonary Rehab 93797-93798, G0237-G0239, G0422-G0424 Ostomy/Wound Care Hyperbaric oxygen wound therapy 99183, G0277 Radiation Therapy 77261-77470 Wheelchair evaluation 97542 no Therapy/Rehabilitation visits 92507-92508,97010-97012, 97022-97024, 97036, 97110-97537, (evaluation does not require a PA) Pharmacy Services Medications (including OTC medications) See formulary for requirements Hospice Services Hospice care (must be Medicare/Medicaid certified hospice) Palliative care Skilled Nursing Facility Services Inpatient skilled nursing care Supplies/Equipment if not included in per diem see Equipment and Supplies section for requirements 15 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
Home Health Services All home health services Home Infusion therapy Supplies/Equipment if not included in per diem Hearing Services Hearing Aids see Equipment and Supplies section for requirements V5030-V5060, V5100, V5120-V5150, V5170-V5190, V5210-V5230, V5242-V5263 Repairs V5014, Total repair cost over DMAP and/or contract allowable of $350 Dietary Counseling/Medical Education Services Medical nutrition therapy 97802-97804 (must use registered dietitian) (after 5 visits per calendar year) Diabetes self-management training G0108-G0109 (after 10 visits per calendar year) Chemical Dependency Services Inpatient medical detox notification required within 48 hours of admission 16 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
Dental Services Verify member's eligiblity and assigned dental Provider in the AllCare Health Provider Portal or by calling AllCare Health. Please contact the Dental Provider to access dental benefits and referrals. Equipment and Supplies Durable Medical Equipment (DME) / Repairs Purchase (includes rent to purchase) or repair (total cost) over DMAP and/ or contract allowable of $350 (excluding services below) All Miscellaneous and/or Not Otherwise Specified all requests must be submitted with an invoice and will be subject to review codes for benefit and coverage limitation DME - Rent to purchase items Apnea Monitor E0618-E0619 *first 3 months do not require a PA - 4th month and thereafter CPAP/BIPAP/Humidifier E0560-E0562, E0565, E0601, E0470-E0472 (must use Lincare or Pacific Pulmonary Services) Oxygen and O2 equipment E0424-E0440, E1390-E1392 (must use Lincare or Pacific Pulmonary Services) (for pediatrics use Northwest Medical) Tens Unit E0720, E0730-E0731 Wound Therapy Pump A6550, A7000, E2402 DME - Purchase Only Compression Stockings (2 pairs per yr) A6530-A6544, A6549 no Enteral Formula B4149-B5200 17 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017
Incontinent Supplies T4521-T4544, A4335 (quantity limits apply) (3-5 years old) (Preferred vendor is Byram Healthcare) Insulin Pump/Continuous Glucose Monitor E0784, A9277-A9278 (Preferred vendor is Byram Healthcare) 18 AllCare CCO (541) 471-4106 Toll free (888) 460-0185 Effective January 1, 2017